Beyond the Golden Ticket: Unveiling the Challenges for International Medical Graduates.

Sir, The percentage of international medical graduates (IMGs) in the US health care work force has been increasing steadily (1). Today, IMGs fill approximately one-third of Pediatric and Internal Medicine residency positions, and one-fifth of Family Medicine residency positions. Most IMGs come from non-English speaking countries, and are consequently confronted by a series of transcultural challenges that include not only language but also sex-role differences, lifestyles and culture (2). Sadly, little attention has been given to the emotional challenges encountered by IMGs in caring for patients – transculturally. Consequently, many emotionally charged issues that arise during graduate medical education are unrecognized and not addressed by the US training programs. Fiscella et al. assessed the transcultural challenges in caring for patients of IMGs and American medical graduates (AMGs) in a primary care residency program (2). Each resident wrote a narrative describing a challenging experience and facilitators then conducted a focus group to discuss these experiences. The written narratives were analyzed first. Themes of acceptance/rejection based on nationality seemed to predominate. For example, one IMG resident reported the following experience from a patient: “I do not want any doc who can not speak English taking care of me.” Another resident wrote: “The moment I entered his room, he (the patient) commented on my accent, which was all too much for him to accept.” One IMG wrote about how he feared being singled out if he made a mistake: “In the beginning, I had fear that I may be punished if I make a small mistake being foreigner.” Language emerged as a challenge particularly in communicating emotional support for patients. “I had difficulty expressing myself on different occasions. At times, I had difficulty understanding especially the inner city language and I have not been able to take an adequate history” an IMG wrote. Another IMG resident wrote about the potential for misunderstanding: “Sometimes the language barrier makes it difficult to ask a question in a way which is easily understood by patient and this communication gap sometimes gives wrong understanding of patient problem.” One IMG wrote about how his cultural background affected his ability to perform gynecologic examinations: “Coming from a culture where men do not perform a physical examination of a female patient, it is not easy to do female exam by a male physician especially breast and genitalia exam.” During the focus group, significantly, none of the IMG residents raised issues of discrimination or rejection; instead, the dominant theme of the discussion focused on providing emotional support transculturally. One IMG resident spoke of his inability to reassure a dying patient that it was his internship that caused him to feel depressed, and it was not the fault of the patient. “She wanted to know if she had done something that was making me so depressed. No, it is nothing with you. I just have too much work these days. I don't have much energy, and I can't communicate very well, and I am not very happy, but you have nothing to do with it.” Another IMG resident spoke of the effect on patient care of taboos regarding men touching women in his own culture. “Being from a culture as a female and male there is a difference. You cannot get too close. and so it can be very difficult sometimes for a foreign graduate to come into a culture where there is a difference between the different sexes.” Balon et al. (1) sought to determine if there is a selection bias against IMG applicants for USA residency training positions in psychiatry. Identical requests for a program application were sent by two resident applicants − one IMG and one graduate of a USA medical school − to 193 residency training programs, and the rate and character of responses were analyzed. The response rate to requests for an application form was significantly higher for the USA medical school graduate (159 responses) than for the IMG (87 responses). The quality of responses were also different in some cases. The authors concluded that some residency programs in psychiatry were attempting to limit the influx of IMG applicants at the very first level − the request for an application form. The reasons for this practice are not known, but discrimination could be a possible explanation. Today, at the onset of a new millennium, one in five physicians practicing medicine in the United States received their initial medical training in another country (2). There are multiple reasons why IMGs emigrate to the United States. These include the high regard for which the USA is held in terms of the quality of medical education, the quality of technological development and the commitment to biomedical research. Some countries train more physicians than their health care can absorb, while others may lack the facilities or expertise to train physicians in certain specialties or subspecialties. Frustration and/or dissatisfaction with advancement opportunities, financing arrangements, health care organization, and the political system may also contribute to physician migration across international borders. In addition, physicians practicing in the USA are perceived as being among the best compensated. For example, American physicians earn more than 3.2 times an Australian physician. It appears that educational and professional opportunities unavailable at home may be drawing force for many foreign-trained physician to the USA. Miller et al. (3) found that between 1994 and 1996 Australia and New Zealand lost over 1000 physicians to the United States. The United States, as a host/destination country, benefits by getting a pool of physicians that it did not train, while there is a loss of taxes that the donor country would not collect from them, not to mention the loss of services that they would have provided. However, despite the common sense aspect of this argument, the “brain drain” issue has rarely been studied and is probably more complex than it appears. Given the increasing number of IMGs in American hospitals, it seems clear that the USA has not discouraged physician influx (“brain drain”) despite problems that may be created for the nations from which they emigrated. Mullan et al. (4) argued that the estimated 5000 IMGs who enter the USA physician workforce each year represent the equivalent of the entire graduating classes of some 50 medical schools around the world. Most IMGs in residency training programs in the United States are not exchange visitors, but are either permanent residents or US citizens (4, 5). In general, IMGs gravitate toward initial residency programs in internal medicine and pediatrics, many of which have unfilled positions; however, they tend to subspecialize at a disproportionately high rate, reducing their net contribution to the generalist pool. A significant proportion of exchange visitors eventually enter into permanent practice in the United States, contrary to the intent of the J-1 visa-based residency training as an international educational exchange program.

A Comparison of Objective Assessment Data for the United States and International Medical Graduates in a General Surgery Residency

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This study examines the comparative distributions of postresident international medical graduates (IMGs) and US medical graduates (USMGs) in high and low poverty areas of US cities. Existing research has established that IMGs are more likely than USMGs to practice in urban areas, yet there is the question whether IMGs locate more frequently than USMGs in urban poverty areas. Data from the 1997 AMA Physician Masterfile and 1990 US Census were merged to classify physicians' practices into low- and high-poverty areas in selected cities. In 14 cities with populations of 2.5 million or more, IMGs were located in a statistically significant disproportion in poverty areas of 7 cities. Of 36 cities with populations of 1,000,000 to 2,499,999, there were 5 cities that had significant IMG disproportions in poverty areas. Of a random sample of 27 cities with populations of 250,000 to 999,999, there were 2 cities that had significant IMG disproportions. Many cities in all three size categories had a large proportionate IMG complement of the total physician workforce located within high-poverty areas. IMGs were found in disproportionate numbers in poverty areas in a number of US cities, especially the very largest ones. These findings are discussed in light of the current debate about a physician surplus and initiatives to reduce the number of IMGs in residency training.

International medical graduates (IMGs) make up a substantial proportion of the physician workforce and play an important role in the care of patients with acute myocardial infarction (AMI). There are concerns that IMGs may provide inferior medical care compared with locally trained medical graduates, but that has not been established. We performed a retrospective cohort study of linked administrative databases containing health care claims of physicians' service payments, hospital discharge abstracts, and patients' vital status. We included 127,275 AMI patients admitted between April 1, 1992, and March 31, 2000, to acute care hospitals in Ontario. We then compared the risk-adjusted mortality rates and adjusted use of secondary prevention medications and cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates. Of the 127,275 admitted AMI patients, 28,061 (22.0%) were treated by IMGs and 99,214 (78.0%) by Canadian medical graduates. The risk-adjusted mortality rates of IMG- and Canadian medical graduate-treated patients were not significantly different at 30 days (13.3% vs 13.4%, P = .57) and at 1 year (21.8% vs 21.9%, P = .63). Furthermore, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medications at 90 days and cardiac invasive procedures at 1 year. The use of secondary prevention medications and cardiac procedures and the mortality of AMI patients were similar, regardless of the origin of medical education of the admitting physician. This information places the care provided by IMGs into perspective and supports the ability of well-selected IMGs in caring for AMI patients.

As a US medical graduate, I was not exposed to the travails of international medical graduates until 1993. That year, having just completed critical care training at the University of Chicago, I joined the faculty of a program where international medical graduates made up most of the trainees. I made this choice because I sensed an opportunity to have a positive impact on education and a community's health outcomes. At the time, some admonished me that I would be throwing away my career on “missionary work.” While this elitist comment sealed the deal, my choice was also prescient. My impact in a place that had not had formal critical care education and team coordination was instant and substantial.1 Eventually, I became program director of internal medicine and was charged with the task of building a top-tier residency. This journey has been simultaneously edifying, frustrating, and inspiring.Data compiled by the National Resident Matching Program (NRMP)2 show that the percentage of international medical graduate (IMG) residents has remained relatively stable during the past decade at 17% to 20% overall and 28% to 36% for internal medicine programs (figure). While the NRMP publishes national specialty-specific match results, it excludes positions offered outside the match, which are often filled by IMGs. Thus, the number of IMGs in residency programs is unknown. Despite the sizeable proportion of IMGs who fill training programs, relatively little scholarly work has examined their demographics, distribution, and performance compared to US medical graduates (USMGs). A few studies and anecdotal data suggest that university programs train a greater percentage of USMGs, and community hospitals may have a higher percentage IMGs.3,4 A single large study of internal medicine residents examined aggregate examination scores over time finding that medical knowledge scores of IMGs compared favorably to those of USMGs.5 Between 1995 and 2000, IMGs “scored higher than graduates of US medical schools on every internal medicine in-training examination at every PGY level.”5 Although overall rates of internal medicine board certification are less in US-born international medical graduates (US-IMGs) than in non–US-IMGs and USMGs,6 no study has reported pass rates for first-time test takers in medicine or other disciplines.As a new program director in 2001, the impediments to simultaneously implementing the Accreditation Council for Graduate Medical Education's (ACGME's) Outcome Project and strengthening the quality of the residency program seemed substantial. First, since the most talented USMGs were more likely to match into university residencies,3,4 our faculty grappled with whether to recruit less highly performing students from American medical schools or high-performing IMGs. In the 1990s our program's few USMGs sometimes performed suboptimally or created administrative headaches. We decided to shift our focus to identifying and recruiting from the best around the world.A second impediment was evident: international medical schools necessarily provide a different experience, and most IMGs have both cultural and medical experience deficits. Training methods vary worldwide; foreign school review by the National Committee on Foreign Medical Education and Accreditation is cursory as compared to the accreditation process of US medical schools.7Our goal was to draw the brightest learners and identify international medical schools with methods that complemented our system. We built a detailed website8 to advertise entry criteria that included top quintile test scores and added qualifications (eg, MPH or PhD issued from a US institution, number of publications, US rotations with strong recommendation letters, board certification from Western medical systems). We recognized that most of our brightest IMG applicants came to the United States focused on subspecialty training. Subspecialties are viewed as the “end-game” for many of the most ambitious and talented IMG students. The goals for many IMGs, especially from developing nations, include US citizenship as well. Accordingly, we crafted a deliberate strategy for landing prestigious subspecialty fellowships that could enhance trainees' candidacy for immigrant visas.9Cultural competence describes clinicians' knowledge, understanding, and application of the racial, ethnic, national, religious, and psychosocial aspects of each patient.10 International medical graduates may have little exposure to US minorities,11,12 which can undermine their effectiveness in clinical care. This lack of exposure extends to the medical culture: they may arrive with little or no training in the unique manner in which we present cases and document care. Another difference is that our medical culture expects trainees to take ownership of patient care, and offer their ideas, rather than simply doing what they are told. Thinking aloud is encouraged in the US system, but can be intimidating to IMGs, especially in environments without perceived psychological safety, particularly environments that welcome team members from various disciplines and at all levels of proficiency to participate and contribute to care.13Despite the accomplishments of our residents,8 some clinician-educators and administrators equate the absence of USMGs as program weakness. Some internal medicine fellowships are out of reach for IMGs. Given a USMG and IMG with equal qualifications, it is reasonable for the USMG to get the job. However some university fellowships did not interview our graduates regardless of their achievements. Perhaps most astonishing, we have encountered IMGs who have risen to positions of authority, who now express the same views that they themselves transcended. Despite a country founded on waves of multicultural immigration, a meritocratic culture, and a profession that prizes respect of persons, IMGs are still set apart from USMGs.Another form of bias resides at the level of US medical students. After 10 years, no matter how strongly our internal medicine program performs, we struggle to match positions with USMGs. As internal medicine has become an ever less popular career selection, the best and brightest USMGs match with top-tier university programs.3,4What we have learned during the past decade has been inspiring.8 Our carefully selected IMGs pass the board examinations on the first attempt at a rate greater than 98% (since 2001) and score in the top decile or quintile of the country on standardized tests. They win local and national research prizes and publish in the peer-reviewed literature. They go on to prestigious university fellowships and excellent primary care practices, where their supervisors rate them as superior across competencies (unpublished data). Many take university faculty posts at some of the best programs in the world.8 Our graduates do everything that the best university-trained physicians do. This is inspiring because our residents arrive with little US medical experience and must learn medicine as quickly as their USMG counterparts, while transcending biases and acquiring cultural competence.Our health care system needs IMGs. Without them, more than 30% of US internal medicine program positions may go unfilled2 and our national primary care shortage might be substantially greater.14 We are a country whose central ethos is predicated on liberty and merit, yet IMGs may remain marginalized. National accrediting bodies espouse cultural competence, while as a system we entertain labels that support stereotypes that are inconsistent with inclusiveness and tolerance. We should embrace IMGs as essential and meritorious contributors to the health of our populace. In an ideal world, “IMG” would not carry stigma and the distinction of national origin would evaporate. After successful completion of an ACGME-accredited residency and board certification, IMGs would be celebrated as consistent with the American experience. We must aspire to cultural competence by embracing and respecting diversity in how we treat both patients and our international colleagues.

IMGs Have Played Critical Role In History of U.S. Psychiatry

International medical graduates (IMGs) have substantial representation among primary care physicians in the USA and consistently report lower career satisfaction compared with US medical graduates (USMGs). Low career satisfaction has adverse consequences on physician recruitment and retention. This study aims to identify factors that may account for or explain lower rates of career satisfaction in IMGs compared with USMGs. Using data from the 2008 Health Tracking Physician Survey, a nationally representative survey, we examined the association between IMG status and career satisfaction among primary care physicians. We used multivariable logistic regression modeling to adjust for a broad range of potential explanatory factors and physician characteristics. The study participants comprise primary care physicians who reported at least 20 h a week of direct patient care activities (N = 1,890). The main measures include respondents' overall satisfaction with their careers in medicine. IMGs were statistically significantly less likely than USMGs to report career satisfaction (75.7% vs. 82.3%; p = 0.005). This difference persisted after adjusting for physician characteristics and variables describing the practice environment (adjusted odds ratio = 0.62; 95% confidence interval, 0.43-0.90). Pediatricians (vs. internists) and those who earned $200,001-250,000 (vs. <$100,000) or >$250,000 were more likely to report career satisfaction, while solo practitioners and those who reported being unable to provide high-quality patient care were less likely to report career satisfaction. After adjusting for a number of variables previously shown to have an impact on career satisfaction, we were unable to identify additional factors that could account for or explain differences in career satisfaction between IMGs and USMGs. In light of the central role of IMGs in primary care, the potential impact of poorer satisfaction among IMGs may be substantial. Improved understanding of the causes of this differential satisfaction is important to appropriately support the primary care physician workforce.

Use of deceptive tactics in physician practices: are there differences between international and US medical graduates?

Back to table of contents Previous article Next article Annual MeetingFull AccessIMG Track Offers Advice, Counsel, and Guidance for International GraduatesVikas Gupta, M.D., M.P.H., Lama Bazzi, M.D.Vikas Gupta, M.D., M.P.H., Lama Bazzi, M.D.Published Online:22 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.54AbstractInternational medical graduates (IMGs) make up about 29% of all psychiatrists practicing in the United States. Because psychiatry has become a very competitive specialty, IMGs face new challenges.Tips on applying for residency, acculturation, immigration, and career paths—these are some of the APA Annual Meeting sessions curated especially for international medical graduates (IMGs) in the IMG track at APA's 2023 Annual Meeting. IMGs make up about 29% of all psychiatrists practicing in the United States. More medical students than ever are applying to psychiatry residency programs, making psychiatry more competitive than it has ever been. While this offers us the hope of building a robust workforce of psychiatrists ready and able to serve communities in need, it presents new challenges and opportunities for IMGs. With these factors in mind, the sessions in the IMG Track are focused on the career needs of IMGs including resident-fellow members and early career psychiatrists.The IMG track includes these sessions:IMGs in American Psychiatry: Past, Present, and Future: Our speakers—Dilip Jeste, M.D., Jair Soares, M.D., Ph.D., Daniel Castellanos, M.D., and Geetha Jayaram, M.B.B.S., M.B.A.—have a breadth of experience that has translated into creative solutions serving not only IMGs, but our entire profession. Our panelists will share their personal experiences and discuss possible solutions to help us transform barriers into opportunities in the domains of administration, advocacy, research, and leadership. They will make recommendations to help IMGs contribute to culturally responsive mental health care, education, research, administration, leadership, and advocacy.Acculturation as a Component of Immigration: Challenges of the Psychiatric Workforce: While moving for a residency position is exciting, the culture shock can be jarring for many IMG residents. The panelists in this session will address acculturation; the barriers to assimilating to a new culture; and the challenges of immigration, finding mentorship, and academic placement. Sanya Virani, M.D., M.P.H., will outline the common questions that immigrants ask as they integrate into a new culture and encounter new experiences such as living and practicing medicine in a new country. Isheeta Zalpuri, M.B.B.S., will discuss the importance of cultivating equity in the professional development of IMGs through mentorship, sponsorship, and coaching. Mohammed Molla, M.D., will discuss challenges related to finding an academic position for non-U.S. international medical graduates after completion of residency, and Vishal Madaan, M.D., will provide statistics pertaining to IMGs and offer practical ideas relevant to different stages in an IMG's career.Challenges for IMGs in Psychiatry in 2023: Top Issues and Solutions: Using case examples and small group discussion, panelists will identify the top challenges for IMGs in today's era and offer practical solutions. Dora-Linda Wang, M.D., will address the challenges in the post-pandemic world; Nhi-Ha T. Trinh, M.D., M.P.H., will cover the topic of dealing with microaggressions; Elie Aoun, M.D., will present on the imposter syndrome; and Ian Hunter Rutkofsky, M.D., will speak on challenges unique to IMGs from Caribbean medical schools.Tips and Tricks for IMGs Applying for Residency: What does it take to match successfully? This session aims to delve into topics like mentorship, interviewing, letters of recommendation, resume/CV, research/scholarly projects, extracurricular activities, board scores, personal statement, commitment to psychiatry, and signaling/tokens as pertaining to the residency application process. Our experienced panel of residency training directors—Benedicto Borja, M.D., Rashi Aggarwal, M.D., Jason Curry, D.O., Almari Ginory, D.O., Farooq Mohyuddin, M.D., and Vineeth P. John, M.D., M.B.A., will share practical strategies to increase the chances of successfully matching, understand the common challenges in the match process, the role of a mentor in navigating these hurdles, and identification of ways to strengthen one's application for the residency match.Navigating Career Paths for IMGs: Charting Your Successful Future: Choosing a career path can be challenging for IMGs and American medical graduates alike, making this an interesting session for any resident fellow member or early career psychiatrist wondering "What next?" This session will delve into career paths in academic psychiatry, public psychiatry, and private practice. Our panelist and session chair, Toni Johnson Liggins, M.D., will identify the pathways and barriers to the development of a successful career in academic psychiatry. Leon Ravin, M.D., will discuss challenges and advantages of providing psychiatric care in state-operated systems and highlight opportunities for influencing health care policies, participating in government task forces and community stakeholder-driven work groups, working with law enforcement, and consulting with state legislatures. Vikas Malik, M.D., will present on different types of private practice models and the challenges in starting and running a successful private practice.We are excited about these sessions and look forward to seeing our IMG colleagues there! ■Vikas Gupta, M.D., M.P.H., and Lama Bazzi, M.D., are the chair and vice chair, respectively, of the IMG Subcommittee of APA's Annual Meeting Scientific Program Committee. ISSUES NewArchived

Letter: Predictors of Academic Neurosurgical Career Trajectory Among International Medical Graduates Training Within the United States.

espite recent increases in the number of US medical graduates, international medical graduates (IMGs) constitute an important part of the US health care system and will continue to be needed to meet the nation’s demands for medical services.1,2 Due to differences in culture, education, and local health care systems, IMG applicants and residents and the institutions preparing them for their professional careers experience financial, social, and political challenges, as well as personal, emotional, and financial hardships. We present the perspective of IMGs and provide practical suggestions for making the selection process and transition into US residency smoother and more efficient. This willbetterprepare thisgroupfor their trainingandservice to their patients and, ultimately, the US health care system. Application and Selection

Incoming International Medical Graduates and the COVID-19 Pandemic: More Than Meets the Eye.

IMGs Share Ways to Adapt to American Health System

Background: In the United States (U.S.), international medical graduates (IMGs) and American medical graduates (AMGs) confront work-related and adjustment challenges during post-graduate year one (PGY-1) of residency.Aim: To understand the challenges that IMGs and AMGs confronted during PGY-1 of a U.S. pediatric residency program from the perspective of the residents themselves.Methods: A purposive sample of PGY-1, PGY-2, and PGY-3 residents participated in three semi-structured focus groups (N = 18). The data were analyzed inductively using a grounded theory approach to identify and verify emergent themes.Results: IMGs confronted work-related and adjustment challenges during PGY-1 that included practicing medicine in the U.S., communicating with medical supervisors and nursing staff, communicating with patients, and relocating to the U.S. AMGs confronted work-related challenges that included medical decision-making and medical licensing.Conclusion: The work-related and adjustment challenges that IMGs and AMGs confronted during PGY-1 suggest that the culture of residency socializes IMGs and AMGs regarding professional expectations and responsibilities. Increased awareness of this socialization process among residency program directors, and interventions based on concrete recommendations, can help enhance PGY-1 for IMGs and AMGs across the medical specialties.